In my last clinical placement at Royal Perth, I came across a situation in which I found myself reluctant to discharge a patient. I was not in fact concerned about the patient's health and safety once out of hospital but the safety of the general community. The patient had come in due to a history of falls, a surprising number of these at the local pubs. Alcohol was not suspected as a factor until his daughter visited and informed the staff that her father did in fact have some alcohol related issues.
In all aspects the patient from a physiotherapy point of view was safe to go home, with only outpatient physiotherapy for rotator cuff damage. During one of our conversations I mentioned that he probably would not be safe enough to drive due to some ROM limitations in his trunk preventing him from checking his blind spot. The patient also had coordination impairments which would not affect him unless he got behind the wheel of a car, where a quick response time is needed. On top of this the patients had the alcohol problem mentioned above.
After this discussion the patient still refused to rule out the chance that he would drive again. This stalled my decision to declare him safe for discharge as I believed he would be a danger to himself and others if he was on the road. I bought this up with the OT who informed me that the patient had been given a pamphlet detailing the legal ramifications if he chose to drive against medical advice.
I still had doubts about whether he would actually follow our advice or just keep on driving anyway. I bought this up with my supervisor and asked her what authority we had in this matter, apparently a new law means all the onus is placed on the patient to report any condition that prevents him from being safe driver. In light of this I made sure that I talked to as many of the team as possible about the patients intention to drive so that the issue was made aware of and was included more specifically in his discharge planning.
Ultimately when it comes to a situation like this, which is not usually considered the PT's domain, we are limited in what we can do about it. This doesn't mean we don't try, a pro-active attitude is needed so that issues such as these can be communicated to the medical and allied health team. We shouldn't assume that someone else will bring the topic up, it is more effective to expose them yourself as soon as you become aware of them.
Monday, June 9, 2008
Communicating effectively
Whilst on the orthopaedic inpatients ward on my last prac I had an experience with a patient and doctor which really reinforced for me the importance of communication in terms of respect for the patient as a person and their right to know what is happening in terms of their management. I had just introduced myself to the patient, an elderly man with a stable Cx fracture who also had a mild hearing impairment, though no significant cognitive deficit. I was almost finished my subjective examination when an intern came in and read the patient's drug chart. Then, without even apologising/asking/acknowledging that I was speaking to him he interrupted and told the patient that one of his medications would need to be changed. He spoke very quietly and I told him that the patient had a mild hearing impairment. Again he spoke to the patient very quietly, and was not heard.
I ended up "interpreting" for the patient by repeating everything the doctor said louder, which seemed very silly to me. He asked several questions about his new bowel condition that was preventing his transfer from the hospital as well as the changes to his medication. After twice not being heard (at a volume that I was stuggling to hear!) the doctor seemed to decide that it wasn't worth explaining things to this man as he wasn't going to understand/hear him. He continued to read the chart, when the patient asked him if he was a pharmacist. The doctor's reply was simply to hold his ID card up (which had his name, photo and the word "Doctor" on it) without so much as a glance up from the chart. To be honest I was quite appalled at this lack of any effort to communicate with the patient and explain things to him simply because he had a minor difficulty. Unsurprisingly the doctor left again without a word to myself or the patient.
For me this experience really reinforced the importance of considering the patient as a whole, and adjusting things, be they communication methods, treatment, management, education etc to suit the patient. In some cases it is extremely difficult to communicate with some patients and effectively get your message across, however more often that not it is a simple change that can make a huge difference, such as the volume of your voice. I also experienced first hand that health professionals do not always consider the patient's understanding of their situation to be important, as demonstrated by a complete lack of effort to provide him with this information.
I think if something like this happened again I would like to constuctively and respectfully suggest things to the person to help them, as part of the team, to communicate their message and answer the patient's questions. I think my surprise at being interrupted and still thinking about what I was doing prevented me really reacting to the situation, instead doing little more than standing there observing. I felt very sorry for the patient, who had no idea why he had the new bowel problems, (despite asking) so would not like to witness this again when it could be so easily avoided.
I ended up "interpreting" for the patient by repeating everything the doctor said louder, which seemed very silly to me. He asked several questions about his new bowel condition that was preventing his transfer from the hospital as well as the changes to his medication. After twice not being heard (at a volume that I was stuggling to hear!) the doctor seemed to decide that it wasn't worth explaining things to this man as he wasn't going to understand/hear him. He continued to read the chart, when the patient asked him if he was a pharmacist. The doctor's reply was simply to hold his ID card up (which had his name, photo and the word "Doctor" on it) without so much as a glance up from the chart. To be honest I was quite appalled at this lack of any effort to communicate with the patient and explain things to him simply because he had a minor difficulty. Unsurprisingly the doctor left again without a word to myself or the patient.
For me this experience really reinforced the importance of considering the patient as a whole, and adjusting things, be they communication methods, treatment, management, education etc to suit the patient. In some cases it is extremely difficult to communicate with some patients and effectively get your message across, however more often that not it is a simple change that can make a huge difference, such as the volume of your voice. I also experienced first hand that health professionals do not always consider the patient's understanding of their situation to be important, as demonstrated by a complete lack of effort to provide him with this information.
I think if something like this happened again I would like to constuctively and respectfully suggest things to the person to help them, as part of the team, to communicate their message and answer the patient's questions. I think my surprise at being interrupted and still thinking about what I was doing prevented me really reacting to the situation, instead doing little more than standing there observing. I felt very sorry for the patient, who had no idea why he had the new bowel problems, (despite asking) so would not like to witness this again when it could be so easily avoided.
Unsure of what went wrong??
Whilst on my hand therapy placement I was treating a young woman who had fallen on a broken bottle and subsequently had lacerated a great portion of her anterior forearm and palm, completely severing the majority of her flexor tendons and median nerve. She had been sutured and plastered initially for 3 weeks before doctors had decided to transfer her from Fremantle to Royal Perth to receive surgical repair. As such, she was immobilised in plaster for a total of 8 weeks prior to receiving therapeutic treatment.
She presented to hand therapy with tethering of the flexor tendons and a hypertrophic scar on the palmar aspect of her right hand that was severly restricting any movement into digital extension or wrist extension. I discussed with one of the senior hand therapists whom I was treating her with whether or not ultrasound would be an option to assist with breaking up the scar tissue as previous treatments with vibration and firm massage was having little effect. My supervisor seemed to think it was worth trying and was happy for me to proceed.
The ultrasound machine that was used at the clinic was old, one of the sonopulse ones, a model that we hadn't used at uni. I had reviewed my settings for ultrasound and selected the settings that would be most appropriate to use to break up scar tissue. Just to be sure I got one of my supervisors to check the machine settings and she was happy for me to proceed. I had gone through all precautionary questions and had performed the necessary sensory tests.
The patient displayed intact sensation and consented to continue treatment. As I was performing the treatment over the area of scar tissue on the palm one of the other hand therapists asked to speak to me outside. The PT asked me abruptly if I thought what I was doing was safe and I replied that I thought it was. He asked me why I thought so and I replied by saying that I had reviewed the unit and parameters, had checked with another PT and had permission by the other senior therapist whom I was treating the patient with as well as going through necessary precautionary sensation tests and questions. He harshy told me that the treatment was not safe and I was putting the staff in an awkward position of responsibility. I was so taken aback that and when I asked why it was unsafe he turned the question back onto me and did not respond. The only thing he said was that I was going too fast and should be moving the ultrasound head in circles. At uni we were taught not to move in circles but rather longitudinally. If the only thing I was doing wrong was going a little too fast, he could have told me in a much more professional way rather than pulling me out of the treatment room and yelling at me in front of all the other hand therapists. He then told me to continue with the treamtent, making no changes to the parameters.
To this day I am still not sure what I did wrong so if anyone can fill me in I would love to know. I know that not all therapists agree with the use of US, however in this instance it was worth giving it a go. I have gone over and over the parameters and still agree with what was chosen as did 2 of my supervisors. I was so embarassed and taken aback by this instance I am not as confident with using US, however I believe that what I did was not irresponsible or endangering the patient in any way.
She presented to hand therapy with tethering of the flexor tendons and a hypertrophic scar on the palmar aspect of her right hand that was severly restricting any movement into digital extension or wrist extension. I discussed with one of the senior hand therapists whom I was treating her with whether or not ultrasound would be an option to assist with breaking up the scar tissue as previous treatments with vibration and firm massage was having little effect. My supervisor seemed to think it was worth trying and was happy for me to proceed.
The ultrasound machine that was used at the clinic was old, one of the sonopulse ones, a model that we hadn't used at uni. I had reviewed my settings for ultrasound and selected the settings that would be most appropriate to use to break up scar tissue. Just to be sure I got one of my supervisors to check the machine settings and she was happy for me to proceed. I had gone through all precautionary questions and had performed the necessary sensory tests.
The patient displayed intact sensation and consented to continue treatment. As I was performing the treatment over the area of scar tissue on the palm one of the other hand therapists asked to speak to me outside. The PT asked me abruptly if I thought what I was doing was safe and I replied that I thought it was. He asked me why I thought so and I replied by saying that I had reviewed the unit and parameters, had checked with another PT and had permission by the other senior therapist whom I was treating the patient with as well as going through necessary precautionary sensation tests and questions. He harshy told me that the treatment was not safe and I was putting the staff in an awkward position of responsibility. I was so taken aback that and when I asked why it was unsafe he turned the question back onto me and did not respond. The only thing he said was that I was going too fast and should be moving the ultrasound head in circles. At uni we were taught not to move in circles but rather longitudinally. If the only thing I was doing wrong was going a little too fast, he could have told me in a much more professional way rather than pulling me out of the treatment room and yelling at me in front of all the other hand therapists. He then told me to continue with the treamtent, making no changes to the parameters.
To this day I am still not sure what I did wrong so if anyone can fill me in I would love to know. I know that not all therapists agree with the use of US, however in this instance it was worth giving it a go. I have gone over and over the parameters and still agree with what was chosen as did 2 of my supervisors. I was so embarassed and taken aback by this instance I am not as confident with using US, however I believe that what I did was not irresponsible or endangering the patient in any way.
Younger patients
On my current clinical placement I am working with a number of patients who are in the same age group as myself. Many of these patients have the same interests as myself, go to the same social locations and do the same things that I do on the weekend. The issue of working with patients in the same age group was raised during mid-placement assessment. My supervisor was interested in knowing how I was coping with the situation, and the following points were made.
There are several issues to be aware of when working with patients in the same age group as ourselves. The first of these is the importance of avoiding burnout by debriefing with colleagues or the like to ensure we are not taking on too much and keeping things to ourselves. One of the hardest things to cope with on this prac has been realizing that these patients were living the same sort of life as you and me before their accidents, and now they have months and years of hard work ahead in order to regain the slightest normalcy back into their lives. My tutor told me an example about a colleague who didn’t debrief or vent about the things she was dealing with at work in a similar situation each day, and eventually she left the profession because she didn’t identify what was bothering her and burnt out emotionally.
The second issue is being able to be both personal and professional towards these younger patients. That is, we need to be able to build rapport, and connect with our patients to increase things like compliance. However in building rapport, we also need to be able to establish a clear ‘patient-therapist’ relationship, without letting age similarities get in the way. Another student mentioned one lunchtime that she had a patient who acted totally differently around her compared to older members of staff, which is not fair, as we need to be respected as professionals in our field, regardless of age. This is as much our responsibility as it is the patient’s and we need to ensure that there are clear lines in the sand outlining our position and their’s, to ensure that the patients receive the best care possible.
I found this discussion with the supervisor to be very useful, and was glad that she identified these things to me. As therapists, we need to take care of ourselves both mentally and physically, and this experience has highlighted to me the importance of talking things over and debriefing about emotional or stressful situations. In the future I will ensure that I share with colleagues, and talk things through to ensure I do not ‘burn out’. It is also important for us to be aware of our professional standing, and to ensure that we are treated correctly with the right amount of respect from our patients. We’ve worked hard to get where we are, and should be treated as such.
Friday, June 6, 2008
Patients in reality...
I have had quite a fair amount of complex patients where either they present with more than one symptom or present with a totally different problem that I was told they are coming in for. This has proved to be very challenging even with two weeks before the end of this placement.
I will usually prepare by planning a standard assessment and reading about the involved joint or area. This has proved to be very helpful in straightforward cases, I am able to be very efficient with time and the session tends to flow seamlessly. However, reality is that people are dynamic creatures and they do not usually fall directly into presentations of conditions that we learn in theory.
With more than one symptom involved, we will have to establish if there is any relationship between the different symptoms which requires detailed questioning about the aggravating factors, fill up the body chart and map the pain pattern throughout the day for the different symptoms. Many a times it feels as though I am seeing 3 or 4 patients combined into one!! This is compounded by the fact that we have to work out all these within a certain period of time which always seems to be too little for me. It also does not help the situation if patients give you random information from everywhere that does not direct the investigation of the symptoms.
Although it is very challenging especially within a set amount of time, I actually welcome the challenge. I believe I need to be a bit firm with patients who tend to ramble, to interrupt them without seeming rude. This is also good practice for me to think on the spot, having all the random information in my head to and being able to organise them into information that forms a clinical picture of the patient in front of me. I guess I might have been too concerned with recording all the details of P1s, R2s, quantity of P2s instead of relying a bit more of my active memory to add all these to the clinical picture that is forming throughout the session. This is a good pit stop to reflect on how I can improve by making full use of the remaining time at this placement to develop the above strategies.
I will usually prepare by planning a standard assessment and reading about the involved joint or area. This has proved to be very helpful in straightforward cases, I am able to be very efficient with time and the session tends to flow seamlessly. However, reality is that people are dynamic creatures and they do not usually fall directly into presentations of conditions that we learn in theory.
With more than one symptom involved, we will have to establish if there is any relationship between the different symptoms which requires detailed questioning about the aggravating factors, fill up the body chart and map the pain pattern throughout the day for the different symptoms. Many a times it feels as though I am seeing 3 or 4 patients combined into one!! This is compounded by the fact that we have to work out all these within a certain period of time which always seems to be too little for me. It also does not help the situation if patients give you random information from everywhere that does not direct the investigation of the symptoms.
Although it is very challenging especially within a set amount of time, I actually welcome the challenge. I believe I need to be a bit firm with patients who tend to ramble, to interrupt them without seeming rude. This is also good practice for me to think on the spot, having all the random information in my head to and being able to organise them into information that forms a clinical picture of the patient in front of me. I guess I might have been too concerned with recording all the details of P1s, R2s, quantity of P2s instead of relying a bit more of my active memory to add all these to the clinical picture that is forming throughout the session. This is a good pit stop to reflect on how I can improve by making full use of the remaining time at this placement to develop the above strategies.
Tuesday, June 3, 2008
Differences in opinion
Extremely sorry for the late reply, forgot that today is in fact Tuesday and not Monday.
My first placement was a Neuro placement in which another student and I were subjected to three different tutors (2 facility supervisors and 1 CCT) who all had a say in our assessment. This was due to our initial facility supervisor going on holiday half way through the prac. Luckily for us all three tutors were experienced, senior PT's with a ridiculous amount of knowledge and the ability to facilitate (sometimes painfully) a great placement for me. The downside of this situation is that all three tutors had significantly different methods to their madness. These differences encompassed how we recorded and set out our notes, our methods of assessment/treatment and the way we interacted with patients.
This led to the fear that our end of prac assessments would be affected due to the fact that we were expected to learn and re-learn three different ways to achieve the same goal. A Neuro placement is hard enough but on top of that how are we supposed to cater to three different clinicians?
Nonetheless I was able to turn my initial frown upside down. I realised that during the final year of my Physiotherapy course I was being given the opportunity to not only learn from practicing PT's but to experiment with and trial different schools of thought. It is unrealistic to think that all PT's go about their business in the same manner and it is up to the student to be able to analyse these different methods so that by the end of the year we have a basic, yet individual philosophy towards our profession and the manner in which we act.
As for the fear of being given a less than satisfactory final assessment, remember that P's get the degrees. We should concern ourselves with taking as much from our learning experience as we can and maybe not worrying too much about our end of prac assessment as that should sort itself out.
My first placement was a Neuro placement in which another student and I were subjected to three different tutors (2 facility supervisors and 1 CCT) who all had a say in our assessment. This was due to our initial facility supervisor going on holiday half way through the prac. Luckily for us all three tutors were experienced, senior PT's with a ridiculous amount of knowledge and the ability to facilitate (sometimes painfully) a great placement for me. The downside of this situation is that all three tutors had significantly different methods to their madness. These differences encompassed how we recorded and set out our notes, our methods of assessment/treatment and the way we interacted with patients.
This led to the fear that our end of prac assessments would be affected due to the fact that we were expected to learn and re-learn three different ways to achieve the same goal. A Neuro placement is hard enough but on top of that how are we supposed to cater to three different clinicians?
Nonetheless I was able to turn my initial frown upside down. I realised that during the final year of my Physiotherapy course I was being given the opportunity to not only learn from practicing PT's but to experiment with and trial different schools of thought. It is unrealistic to think that all PT's go about their business in the same manner and it is up to the student to be able to analyse these different methods so that by the end of the year we have a basic, yet individual philosophy towards our profession and the manner in which we act.
As for the fear of being given a less than satisfactory final assessment, remember that P's get the degrees. We should concern ourselves with taking as much from our learning experience as we can and maybe not worrying too much about our end of prac assessment as that should sort itself out.
Late to appointments
Whilst on prac in musculoskeletal outpatients earlier this semester I encountered a private (ie paying per session) patient who was always late for her appointments. Between the student before me and I we had diagnosed as a medial collateral ligament sprain and medial meniscal tear of her knee. Follow-up appointments were initially one hour in length, and the patient was 15, 20 and 35minutes late for her first three appointments with me. For two of those she also had to leave 5-10 minutes before the scheduled finish time, which she informed me of at the start of the sessions.
I was becoming increasingly annoyed and frustrated as it became evident that this was not a one-off, and that she clearly expected me to race through assessments and treatments, without any concern for the pressure that put me under as a student. She would say things like "Oh don't worry about measuring that again, it's basically the same again" when I was reassessing my asterisk signs to determine the brief treatments I would provide. It felt to me like she had very unrealistic expectations - that she could turn up when she was ready for 20 minutes after being told she needed to allow an hour for all sessions, and that I could just spend all that time treating the impairments that may or may not have been getting better without me knowing. In addition to this, I believe she was not resting her knee as I was recommending she do - with the limited treatment I had time to provide and constant exacerbation on her part, her knee was not going to get better for some time. This also seemed to frustrate her (understandably), even when I explained this to her.
When she turned up 35mins late to the third appointment I told her that I could not treat her, as it was unfair to me, her (in terms of responding to treatment) and patients I had after seeing her if we went overtime, which was quite likely. She was not pleased to hear this at all, however my supervisor backed me up and she seemed to understand after several minutes of discussion. I suggested other options, such as qualified outpatient clinics where 20mins is a much more realistic session length, however she would still need to be on time for them as they would have a similar policy. She did not like this idea either, however she did not come back to our clinic, so she may have followed this path.
This was the only time something like this happened on my 5 week placement, however I think it was a useful experience to be put in the position where I had to put my foot down about how I was being treated. It was difficult in that she was willing to pay for the treatments and have them rushed through, though I felt it was not as effective as it should be and that I was being put under additional pressure.
After the first session I assumed her lateness was a one-off and didn't make an issue of it as she apologised and blamed traffic. At the second visit I did mention that she needed to be on time, however in hindsight I think I should have made it clear how important this was for all parties. I think being clearer when addressing the patient's expectations and trying to make them more realistic earlier on would also help to prevent her lateness and frustration with her progress, gaining better compliance to education and treatment. Does anyone else have any other suggestions of how to deal with this sort of problem or better still, prevent it?
I was becoming increasingly annoyed and frustrated as it became evident that this was not a one-off, and that she clearly expected me to race through assessments and treatments, without any concern for the pressure that put me under as a student. She would say things like "Oh don't worry about measuring that again, it's basically the same again" when I was reassessing my asterisk signs to determine the brief treatments I would provide. It felt to me like she had very unrealistic expectations - that she could turn up when she was ready for 20 minutes after being told she needed to allow an hour for all sessions, and that I could just spend all that time treating the impairments that may or may not have been getting better without me knowing. In addition to this, I believe she was not resting her knee as I was recommending she do - with the limited treatment I had time to provide and constant exacerbation on her part, her knee was not going to get better for some time. This also seemed to frustrate her (understandably), even when I explained this to her.
When she turned up 35mins late to the third appointment I told her that I could not treat her, as it was unfair to me, her (in terms of responding to treatment) and patients I had after seeing her if we went overtime, which was quite likely. She was not pleased to hear this at all, however my supervisor backed me up and she seemed to understand after several minutes of discussion. I suggested other options, such as qualified outpatient clinics where 20mins is a much more realistic session length, however she would still need to be on time for them as they would have a similar policy. She did not like this idea either, however she did not come back to our clinic, so she may have followed this path.
This was the only time something like this happened on my 5 week placement, however I think it was a useful experience to be put in the position where I had to put my foot down about how I was being treated. It was difficult in that she was willing to pay for the treatments and have them rushed through, though I felt it was not as effective as it should be and that I was being put under additional pressure.
After the first session I assumed her lateness was a one-off and didn't make an issue of it as she apologised and blamed traffic. At the second visit I did mention that she needed to be on time, however in hindsight I think I should have made it clear how important this was for all parties. I think being clearer when addressing the patient's expectations and trying to make them more realistic earlier on would also help to prevent her lateness and frustration with her progress, gaining better compliance to education and treatment. Does anyone else have any other suggestions of how to deal with this sort of problem or better still, prevent it?
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